Pain Treatment and Medication
Abuse in the Veterans Healthcare
Administration
As the topic of this conference addresses, Traumatic Brain Injury is perhaps the
signature injury associated with the different battlegrounds of the War on
Terror. However, as most of you associated with the treatment of veterans
realize, the co-morbid conditions that frequently accompany TBI is Post
Traumatic Stress Disorder and substance abuse. Less well discussed, though
just as prevalent as TBI, is acute and chronic pain among OEF/OIF veterans.
These three conditions are unique in that their close association involves the
same etiology for TBI and PTSD, while the substance abuse, particularly
medication abuse and addiction, has a different etiology.
The experience of chronic pain is intensified by the symptoms of TBI and PTSD
and may be a major contributor to depression among veterans. All three have
the effect of limiting the recreational, vocational and social activities of
veterans who prior to their combat experience had a significantly greater range
of life experiences and options in each area.
There is in the civilian arena on-going debate of the efficacy of opiate pain
medication as an effective treatment modality for chronic pain. This is also a
very poignant topic within the Department of Defense and the Veterans
Administration. The Veterans Healthcare Administration is committed to the
wellbeing of the “whole Veteran”, including effective treatment of chronic pain
issues.
VHA Directive 2009-053 provides direction for the Veterans Medical Centers to
provide effective and clinically appropriate pain management services to all
veterans with legitimate pain issues. This directive states: “ The overall objective
of the national strategy is to create a comprehensive, multi-cultural, integrated,
system wide approach to pain management that reduces pain and suffering and
improves the quality of life for Veterans experiencing acute and chronic pain
associated with a wide range of illnesses, including terminal illness. The VHA
employs a wide range of stepped-care model of pain care that provides for the
management of most pain conditions in a Primary Care setting. This is supported
by timely access to secondary consultation from pain medicine, behavioral
medicine, physical medicine and rehabilitation, specialty consultation, and care
coordination with palliative care, tertiary care, advanced diagnostic and medical
management and rehabilitation services for complex cases involving comorbidities such as mental health disorders and traumatic brain injury (TBI).”
The use of addictive pain medication, particularly opioid pain medication has been the
primary means of pain management for a significant period of time, particularly on the
battlefield where it is perhaps the most effective, immediate and most easily
administered form of pain medication. Opioid pain medication is also the least costly and
remains the primary pain medication modality with in the Department of Defense health
care arena. Many OEF/OIF veterans are discharging from the armed services and
enrolling with the VA already having been put on an opioid pain medication regimen for
some period of time. As should be evident from this seminar already, the symptomology
of TBI and PTSD make adhering to a strict prescribed pain medication regimen difficult
for many Veterans and perhaps even unlikely if they experience significant mental
health, social and economic challenges and hardships upon their return to civilian life.
Part of the problem resides in the confusion of how to treat acute pain versus chronic
pain. Opiates are a first line in treating acute pain but are only one of multiple options
for chronic pain. The lack of understanding of the difference in acute pain versus chronic
pain is a large part of how we got here and why opiate prescription is so high. Physicians
are trained in acute pain but not necessarily in chronic pain. The goals of treatment of
acute pain is to make the pain go away but the goals of treatment of chronic pain is to
improve quality of life, better physical functioning
The following chart shows the number of encounters ( contacts with providers—
visits) and the number of unique Veteran patients treated for active pain
problems at the main Muskogee VA Medical Center, as well as the Outpatient
Clinics in Tulsa, Vinita and Hartshorne. The most startling statistic is the
percentage of all individual veterans seen at each facility that have active pain
problems. These percentages are for all veterans, not just OEF/OIF Veterans. The
higher percentages at Muskogee and Tulsa are due to the availability of specialty
services available there which are not available at this time at Vinita and
Hartshorne.
UNIQUE PATIENTS WITH ACTIVE PAIN PROBLEMS
WITHIN LAST 12 MONTHS
ACTIVE PATIENTS (SEEN IN PAST 24 MONTHS)
Division
McAlester
Muskogee
Tulsa
VINITA CBOC
# Unique Encounters
2299
46681
28514
1873
# Unique Encounters
Active Patients (seen in past 24 months)
VINITA CBOC,
1873, 2.4%
Tulsa, 28514,
35.9%
#Unique # OF Pain Pain Problems
Patients Problems per Unique Pt
440
908
2.1
5113
13305
2.6
3473
8544
2.5
Division
McAlester
Muskogee
Tulsa
VINITA CBOC
427
843
2.0
#Unique Patients with Active Pain Problem (seen in
past 12 months)
VINITA CBOC,
427, 4%
McAlester,
2299, 2.9%
McAlester, 440,
5%
Tulsa, 3473, 37%
Muskogee,
46681, 58.8%
Muskogee, 5113,
54%
The Jack C. Montgomery VA Medical Center has undertaken an initiative to address
these significant pain issues of our veterans. The establishment of a comprehensive
Pain Management Clinic composed of a multi-disciplinary team is one of the FY 11
strategic goals for the Medical Center. The initial proposal by an existing Pain
Management Committee includes the following:
A Multidisciplinary Team composed of:
•Anesthesiologist for specialized injections
•Physician or Nurse Practitioner with
Pain Management training
•Pain Psychologist
•RN
•Physical Therapist
•Medical Social Worker
•Clinical Pharmacist
•Occupational Therapist
•Recreational Therapist
•Administrative Support Assistant
A comprehensive program that is focused on patient centered care and patient goals
and would potentially include such treatments as:
•Comprehensive pain and physical evaluations in a timely manner
•Coordination of needed tests or studies
•Development of a comprehensive treatment plan
•Education of primary care providers on the Veteran’s Treatment Plan
•Development of monitoring outcomes of the pain treatment plan
•Documentation of pain control/management
•Pain Medication Management
•Reiki therapy
•Acupuncture
•MOVE Program for weight control and fitness
•Biofeedback
•Injection Clinic
•Pain Psychology Therapy
Group Therapy: Cognitive Behavioral Pain therapy; Relaxation Group; Problem Solving
and Goal Setting Group; ACT for pain group; Yoga for pain Group.
Physical Therapy
Occupational Therapy
Hydro Therapy( whirlpool and endless pool-swimming)
Substance (Medication included) Abuse/Addiction education, therapy and Relapse
Preventions
This model represents the Biopsychosocial Model and it is different in that it
changes the emphasis from simply alleviating pain and focuses on eliminating
suffering. The pain is not ignored, rather the other factors influencing the
experience suffering versus a quality of life are addressed, i. e.: fear of pain or reinjury; physical de-conditioning; fatigue; adverse effects of medication; the
influence of other and the unwillingness of the workplace to help with
accommodations for disability; the loss of income; reduction of pleasant activities;
social isolation; fears of physical incapacitation; fears of or experience of strain/loss
of relationships; fears of loss of productivity and fear of being incapacitated
psychologically.
The imperative for an active pain management program to alleviate Veterans suffering
is further intensified by the fact that the in the last two Annual Suicide Aggregate Root
Cause Analysis Reviews conducted by the Jack C. Montgomery VAMC have clearly
revealed that the number one method of suicide attempt by Veterans in our
catchment area was by overdose on prescribed pain medication. Also, the number of
suicide attempts for the Jack C. Montgomery VA Medical Center’s catchment area was
second in our VISN (Region) to Houston VAMC by only a few attempts. Furthermore, a
recent national study revealed that Oklahoma led the nation in prescription
medication abuse. These facts clearly indicate a problem of major significance that
impacts all Oklahoma communities. To think that the VA alone can meet the needs of
Veterans with these issues lacks understanding since the Veterans are residing in a
local social environment that is experiencing the same issues as the Veterans. To meet
the needs of Veterans and to truly effect a positive readjustment to civilian life, we
must have available treatment for the veterans, their families and social relationships.
The VA is committed to the development of collaborative efforts with state and
local agencies to address these issues. While the VA is currently beginning to
reverse the past policies of treating veterans only by beginning to offer services to
the families of veterans, the process of gearing to do that effectively is slow. There
seems to be great opportunity for the VA to collaborate with community agencies
and programs in addressing the supplemental needs of Veterans (i.e. peer support
mentors) and in serving the families of veterans. There are some community
resources that perhaps have not been fully developed, but who have a history of
past collaboration, examples are Veterans Service Organizations, local pastors and
Pastor Alliances. There are many new collaborative relationships that can be
developed that will enable us to serve the “whole” veteran—personally, his family,
his employment environment and his recreational/social environment.
What are some of your ideas?